The sevoflurane concentration for light sedation in critically ill patients: A protocol for experimental study
Sevoflurane for light sedation in critically ill
DOI:
https://doi.org/10.54205/ccc.v32.268709Keywords:
Sevoflurane, Sedation, Light sedation, Inhaled sedation, Critical illness, Critical careAbstract
Background: Deep-inhaled sedation is increasingly used in Thai ICUs. However, there is a lack of information regarding the level of end-tidal sevoflurane concentration during light sedation.
Objectives: The study aims to determine the effective dose (ED50 and ED95) of sevoflurane concentration for light sedation (RASS score -1 to 0) in mechanically ventilated critically ill patients.
Methods: This is a prospective experimental single-center study. Mechanically ventilated patients with RASS ≥ 1 who required sedation in the medical and surgical intensive care unit were enrolled. Using an up-and-down sequential allocation technique, the inhaled sevoflurane level of each patient was allocated based on the previous patient’s response. RASS score and hemodynamic parameters were monitored. The primary outcome was the ED50 and ED 95 of end-tidal sevoflurane concentration. The secondary outcomes included the length of intensive care unit stay, duration of ventilator day, the incidence of delirium, hemodynamic status, and respiratory variables changed during the study period.
Hypothesis: There exist specific end-tidal sevoflurane concentrations (ED50 and ED95) that will reliably induce a target RASS score of -1 to 0 in critically ill patients who are mechanically ventilated.
Conclusion: This study will provide an effective dose of inhaled sevoflurane sedation for achieving targeted light sedation levels in critically ill patients, which may have minimal effects on hemodynamics.
Ethics and dissemination: This study has been approved by the Office of Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand, on 22nd May 2023 (COA.MURA2023/390).
Trial registration: TCTR20230825001
References
Tate JA, Devito Dabbs A, Hoffman LA, Milbrandt E, Happ MB. Anxiety and agitation in mechanically ventilated patients. Qual Health Res. 2012;22:157-73.
Devlin JW, Skrobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46:e825-e73.
Vincent J-L, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA, Spronk P, et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Medicine. 2016;42:962-71.
Treggiari MM, Romand JA, Yanez ND, Deem SA, Goldberg J, Hudson L, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med. 2009;37:2527-34.
Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. The Lancet. 2010;375:475-80.
Shehabi Y, Chan L, Kadiman S, Alias A, Ismail WN, Tan MA, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med. 2013;39:910-8.
Tanaka LM, Azevedo LC, Park M, Schettino G, Nassar AP, Rea-Neto A, et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care. 2014;18:R156.
Jakob SM, Ruokonen E, Grounds RM, Sarapohja T, Garratt C, Pocock SJ, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307:1151-60.
Ruokonen E, Parviainen I, Jakob SM, Nunes S, Kaukonen M, Shepherd ST, et al. Dexmedetomidine versus propofol/midazolam for long-term sedation during mechanical ventilation. Intensive Care Med. 2009;35:282-90.
Miyagawa N, Kawazoe Y, Sato T, Kushimoto S, Miyamoto K, Ohta Y, et al. Comparison between midazolam and propofol in acute phase for ventilated patients with sepsis: a post-hoc analysis of the DESIRE trial. Acute Medicine & Surgery. 2022;9:e746.
Shi HJ, Yuan RX, Zhang JZ, Chen JH, Hu AM. Effect of midazolam on delirium in critically ill patients: a propensity score analysis. J Int Med Res. 2022;50:3000605221088695.
Jerath A, Parotto M, Wasowicz M, Ferguson ND. Volatile Anesthetics. Is a new player emerging in critical care sedation? Am J Respir Crit Care Med. 2016;193:1202-12.
Preckel B, Bolten J. Pharmacology of modern volatile anaesthetics. Best Pract Res Clin Anaesthesiol. 2005;19:331-48.
Rohm KD, Mengistu A, Boldt J, Mayer J, Beck G, Piper SN. Renal integrity in sevoflurane sedation in the intensive care unit with the anesthetic-conserving device: a comparison with intravenous propofol sedation. Anesth Analg. 2009;108:1848-54.
Purrucker JC, Renzland J, Uhlmann L, Bruckner T, Hacke W, Steiner T, et al. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa(R): an observational study. Br J Anaesth. 2015;114:934-43.
Rohm KD, Wolf MW, Schollhorn T, Schellhaass A, Boldt J, Piper SN. Short-term sevoflurane sedation using the Anaesthetic Conserving Device after cardiothoracic surgery. Intensive Care Med. 2008;34:1683-9.
Jerath A, Beattie SW, Chandy T, Karski J, Djaiani G, Rao V, et al. Volatile-based short-term sedation in cardiac surgical patients: a prospective randomized controlled trial. Crit Care Med. 2015;43:1062-9.
Mesnil M, Capdevila X, Bringuier S, Trine P-O, Falquet Y, Charbit J, et al. Long-term sedation in intensive care unit: a randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam. Intensive Care Medicine. 2011;37:933-41.
Jerath A, Panckhurst J, Parotto M, Lightfoot N, Wasowicz M, Ferguson ND, et al. Safety and efficacy of volatile anesthetic agents compared with standard intravenous midazolam/propofol sedation in ventilated critical care patients: A meta-analysis and systematic review of prospective trials. Anesth Analg. 2017;124:1190-9.
Ruszkai Z, Bokretas GP, Bartha PT. Sevoflurane therapy for life-threatening acute severe asthma: a case report. Can J Anaesth. 2014;61:943-50.
Volta CA, Alvisi V, Petrini S, Zardi S, Marangoni E, Ragazzi R, et al. The effect of volatile anesthetics on respiratory system resistance in patients with chronic obstructive pulmonary disease. Anesth Analg. 2005;100:348-53.
Babaev BD, Ostreikov IF, Shtatnov MK, Apostolidi EY, Nikitin VV, Nadbitova RA. [the Use of volatile agents for sedation in children in the Intensive Care Unit]. Anesteziol Reanimatol. 2015;60:19-22.
Krishna B. Inhaled anesthetics for sedation in ICU: Widening Horizons! Indian J Crit Care Med. 2022;26:889-91.
Gonzalez-Rodriguez R, Munoz Martinez A, Galan Serrano J, Moral Garcia MV. Health worker exposure risk during inhalation sedation with sevoflurane using the (AnaConDa(R)) anaesthetic conserving device. Rev Esp Anestesiol Reanim. 2014;61:133-9.
Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, et al. Safety and Feasibility of AnaConDa to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med. 2022;26:906-12.
Heider J, Bansbach J, Kaufmann K, Heinrich S, Loop T, Kalbhenn J. Does volatile sedation with sevoflurane allow spontaneous breathing during prolonged prone positioning in intubated ARDS patients? A retrospective observational feasibility trial. Annals of Intensive Care. 2019;9:41.
Jung S, Na S, Kim HB, Joo HJ, Kim J. Inhalation sedation for postoperative patients in the intensive care unit: initial sevoflurane concentration and comparison of opioid use with propofol sedation. Acute Crit Care. 2020;35:197-204.
Pace NL, Stylianou MP. Advances in and limitations of up-and-down methodology: a precis of clinical use, study design, and dose estimation in anesthesia research. Anesthesiology. 2007;107:144-52.
Migliari M, Bellani G, Rona R, Isgrò S, Vergnano B, Mauri T, et al. Short-term evaluation of sedation with sevoflurane administered by the anesthetic conserving device in critically ill patients. Intensive Care Medicine. 2009;35:1240-6.
Soukup J, Michel P, Christel A, Schittek GA, Wagner NM, Kellner P. Prolonged sedation with sevoflurane in comparison to intravenous sedation in critically ill patients - A randomized controlled trial. J Crit Care. 2023;74:154251.
Spence J, Belley-Cote E, Ma HK, Donald S, Centofanti J, Hussain S, et al. Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis. Br J Anaesth. 2017;118:658-69.
Hellstrom J, Owall A, Bergstrom J, Sackey PV. Cardiac outcome after sevoflurane versus propofol sedation following coronary bypass surgery: a pilot study. Acta Anaesthesiol Scand. 2011;55:460-7.
Dikmen Y, Eminoglu E, Salihoglu Z, Demiroluk S. Pulmonary mechanics during isoflurane, sevoflurane and desflurane anaesthesia. Anaesthesia. 2003;58:745-8.
Balogh AL, Petak F, Fodor GH, Sudy R, Babik B. Sevoflurane relieves lung function deterioration after cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2017;31:2017-26.
Lutchen KR, Hantos Z, Petak F, Adamicza A, Suki B. Airway inhomogeneities contribute to apparent lung tissue mechanics during constriction. J Appl Physiol (1985). 1996;80:1841-9.
Habre W, Petak F, Sly PD, Hantos Z, Morel DR. Protective effects of volatile agents against methacholine-induced bronchoconstriction in rats. Anesthesiology. 2001;94:348-53.
Turktan M, Gulec E, Hatipoglu Z, Ilginel MT, Ozcengiz D. The Effect of sevoflurane and dexmedetomidine on pulmonary mechanics in ICU patients. Turk J Anaesthesiol Reanim. 2019;47:206-12.
Pellet PL, Stevic N, Degivry F, Louis B, Argaud L, Guerin C, et al. Effects on mechanical power of different devices used for inhaled sedation in a bench model of protective ventilation in ICU. Ann Intensive Care. 2024;14:18.
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